In a forthright and outspoken interview, Professor Srinath Reddy, president of the Public Health Foundation of India, a member of the WHO’s executive committee handling the solidarity trials and a former head of cardiology at AIIMS, says the increase in COVID-19 cases to over 236,000 on Saturday (June 6), placing India sixth in terms of overall cases and third in terms of new cases, is worrying and calls for action by the government. At another point in the interview he said the increase was “alarming”.
However, Reddy did add that given India’s population size, such increases were to be expected. Asked whether the government was right in refusing to accept that India has entered the stage of community transmission, Reddy said he did not want to get into semantics but added that India is seeing a rising number of cases and this could spread across the country. At one point in the interview he even said “we are dealing with community transmission”. The government, he added, prefers to see this in terms of several bush fires rather than one wild forest fire.
In a 43-minute interview to Karan Thapar for The Wire, Reddy made clear that he does not take seriously the mathematical modelling presented by the government on May 22, which suggests that up to 2.9 million cases have been averted. “I would not take the claim on cases seriously,” he said. This is because the criteria for testing as well as the methods used for testing have varied.
However, Reddy said that he was more willing to accept the mathematical modelling on the number of deaths averted. Yet even in this instance, he added, “I would not go with the upper range” of averted deaths. This was the Boston Consultancy Group estimate of 2.1 lakh prevented deaths. Reddy said it was “a bit off the mark”. However, the lower range of 65-78,000 averted deaths could be correct.
Reddy told The Wire there was concern that the tens of millions of migrants returning to their villages in rural Bihar, UP, Bengal, Odisha, Chhattisgarh, Jharkhand, etc. could spread the virus and he firmly believed they should have been allowed to go back in March rather than May. However, he added, he did not believe that the returning migrants would create a huge surge in infections because, as he explained, the RO factor which determines how many people an infected person in turn infects depends upon mobility. In rural India, mobility is a lot less than in urban India.
Reddy expressed concern about the ability of the healthcare system in rural India to handle any increase in infections. He said it was very “patchy”. Some states like Odisha would be better able to handle an increase in rural infections but others in the North or North East would be less able to do so. He added that only a well-functioning healthcare system can rapidly build itself up to handle an emergency. That’s not the case in many states.
Asked by The Wire what he considers the gains of the lockdown, Reddy said that during the first two stages it had slowed down the spread of the virus and it had also provided an opportunity for the healthcare system to prepare itself better. A third gain was that it had given the country a chance to accept and adopt social protection measures but, he added, this was done patchily. He also said that some of the gains of the lockdown could have been lost in the last few weeks as the numbers of infected have started to rise substantially.
Reddy agreed with The Wire that it was a “mugs game” to try and predict when the peak of infections would happen in India. He said many optimistic predictions have been made in the past and found to be incorrect. Also, he added, increasing cases of infections could also be a reflection of the fact that earlier India was not testing enough and now, as tests increase, the number of people found to be infected can go up sharply.
Reddy was questioned about the 3-4 statistics the government repeatedly cites to show that the handling of COVID-19 is well within its control. He was dismissive of the stress the government puts on the recovery rate (48%). He called it “a bit of a misguided number”. He added that it reflects what happened two or three weeks earlier because that is when the person first got infected. He also said most people will recover. Spain with 27,134 deaths has a recovery rate of 69% and Italy with 33,774 deaths as a recovery rate of 70%.
Questioned about the doubling rate (15 days), Reddy told The Wire that it is only useful in the initial stages of an epidemic and not later. He also pointed out that as the number of cases keeps rising the doubling rate slows down. This is why the UK and US have doubling rates of 35 days, Italy 55 days and Spain 56 days.
Reddy said that he places much more reliance on the mortality rate (2.82% compared to a global average of 6.13%). However, he pointed out that if the mortality rate is the case fatality rate there are legitimate questions that can be raised about the way it’s calculated. For instance, as you increase the number of tests you also increase the denominator which, in turn, will shrink the CFR. He said that rather than compare countries in terms of their overall mortality rate it would be better to calculate the rate in terms of age groups and then compare them.
Questioned by The Wire whether he accepts the health minister’s claim (made to the Economic Times) that the virus is “not that virulent” in India, Reddy said that the smaller percentage of cases in India requiring hospitalisation, ICU or ventilators compared to Europe and the US could be explained by multiple factors and he preferred to do so in terms of either the age profile of the country (90% are under 60) or the immunity of the Indian people because of things like the BCG and polio vaccine, which means that their ability to combat the virus is greater. However, he added that this would also be true of our neighbours in South Asia as well as South East Asia.
Reddy said the Delhi government’s decision to narrow and make more stringent the criteria on which testing is done is not the right approach. At this stage and with this number of infections it was important to test people who have come in contact with a COVID-19 confirmed case even if they are themselves asymptomatic. However, Reddy added that testing cannot be done haphazardly in a county of India’s size. It has to be directed and targeted.
Reddy said that a country of India’s size cannot depend on testing alone to map the scale of the spread of the infection in the population. Even the ICMR’s proposed serological sentinel survey (covering 69 out of 739 districts) is not sufficient. A household syndromic surveillance needs to be done. In other words, people need to go household by household to ask both about the influenza-like symptoms that people might have or might have had and also to find out about household deaths and sympathetically establish whether the persons who have died had shown COVID-19 like symptoms even if their deaths were not reported as a COVID-19 death.
Finally, Reddy accepted that there were serious questions about whether the COVID-19 death rate was accurately counted in India. He said deaths in hospitals were likely to be accurate but those out of hospital may be more difficult to be certain of. But even if we are under-counting COVID-19 deaths threefold he said they would still be a lot less than deaths in other countries of Europe and the US.
Speaking about Professor Gautam Menon’s modelling which suggests that there could be 10 million undetected infections in India, Reddy said that would be a good sign because it would show the virus is not killing in large numbers.